瘢痕子宫患者孕期发生子宫破裂的临床分析

Clinical analysis of scarred uterus patients with uterine rupture during pregnancy

目的探讨瘢痕子宫患者妊娠后,孕期发生子宫破裂的临床特点及高危因素。方法选择2016年1月至2019年12月,成都市妇女儿童中心医院收治的瘢痕子宫患者妊娠后,孕期发生子宫破裂的106例患者为研究对象。其中,由于既往剖宫产术导致瘢痕子宫患者再次妊娠后,孕期发生子宫破裂者为95例(89.6%);由于非剖宫产术(子宫穿孔术、子宫角楔形切除术、子宫肌瘤剔除术)导致瘢痕子宫患者妊娠后子宫破裂者为11例(10.4%)。采取回顾性分析法,将95例剖宫产术后瘢痕子宫患者,按照再次妊娠后,孕期发生子宫破裂类型,将其分别纳入完全性子宫破裂(CRU)组(n=17)和不全性子宫破裂(ICRU)组(n=78)。采取Mann-Whitney U检验、χ^2检验或连续性校正χ^2检验,对CRU组与ICRU组患者的临床病例资料进行统计学比较。本研究遵循的程序,符合2013年修订的《世界医学协会赫尔辛基宣言》要求。结果①孕期瘢痕子宫破裂发生率:2016年1月至2019年12月,本院瘢痕子宫患者孕期子宫破裂发生率为0.129%(106/82157);每年瘢痕子宫患者孕期子宫破裂发生率总体比较,差异有统计学意义(χ^2=26.490,P<0.001)。②临床特点分析:本组106例患者的年龄为32岁(19~40岁);104例(98.1%)瘢痕子宫破裂发生在晚孕期(≥28孕周),2例发生在中孕期(20~27+6孕周);74例(69.8%)破裂者无典型子宫破裂症状,32例(30.2%)有典型子宫破裂症状。在11例非剖宫产术后瘢痕子宫患者中,发生严重不良妊娠结局为8例,包括死胎、新生儿窒息、失血性休克及子宫切除术各为3、5、3及2例。③CRU组与ICRU组比较:孕次、产次、既往剖宫产术分娩次数构成比比较,差异均无统计学意义(P>0.05);CRU组患者年龄、孕龄、本次妊娠距离前次剖宫产术分娩间隔时间及临产率,均大于、小于、短于及高于ICRU组,并且差异均有统计学意义(Z=14.323、P<0.001,Z=-32.578、P<0.001,Z=-7.268、P<0.001,χ^2=4.720、P=0.030)。④治疗与随访结果:本组106例患者中,3例接受子宫切除术,18例于剖宫产术中接受双侧输卵管结扎术及子宫修补术,85例接受剖宫产术分娩及子宫修补术。对其中保留生育功能的85例患者随访5~52个月,无一例再次妊娠。结论瘢痕子宫患者妊娠,是导致孕期子宫破裂的高危因素,剖宫产术后瘢痕子宫患者最为常见。剖宫产术后瘢痕子宫患者再次妊娠时,其发生CRU与本次妊娠距离前次剖宫术分娩间隔时间密切相关。对于非剖宫产术后瘢痕子宫患者妊娠时,若其发生子宫破裂,则后果往往更严重。

Objective To analyze clinical characteristics and high risk factors of scarred uterus with uterine rupture during pregnancy.Methods From January 2016 to December 2019,a total of 106 scarred uterine pregnant women with uterine rupture during pregnancy in Chengdu Women′s and Children′s Central Hospital were selected as research subjects.There were 95 cases(89.6%)uterine rupture during re-pregnancy in scarred uterine pregnant women after cesarean section,and 11 cases(10.4%)patients with uterine rupture during pregnancy in scarred uterine pregnant women after non-cesarean section,such as uterine perforation,uterine horn wedge resection,and uterine myomectomy usually.According to types of uterine rupture after cesarean section during re-pregnancy,95 cases scarred uterine pregnant women with uterine rupture after cesarean section during re-pregnancy were divided into complete uterine rupture(CRU)group(n=27)and incomplete uterine rupture(ICRU)group(n=79).Clinical data of CRU group and ICRU group were compared by Mann-Whitney U test,chi-square test or continuous correction chi-square test.The procedures followed in this study were in line with the requirements of World Medical Association Declaration of Helsinki revised in 2013.Results①The rate of uterine rupture in scarred uterine pregnant women during pregnancy was 0.129%(106/82157)from January 2016 to December 2019 in our hospital.There were statistically different in rates of uterine rupture among these four years by overall comparison(χ^2=26.490,P<0.001).②The average age of 106 patients was 32 years old(19-40 years),and 104 cases(98.1%)pregnant women whose uterine ruptures happened in third trimester(≥28 gestational weeks)and 2 cases(1.9%)in second trimester(20-27+6 gestational weeks).Uterine ruptures among these 106 pregnant women,74 cases(69.8%)had no any typical clinical manifestations,and the other 32 cases(30.2%)had typical clinical manifestation.Among 11 patients with scarred uterine after non-cesarean section,8 cases had serious adverse pregnancy outcomes,including stillbirth,neonatal asphyxia,hemorrhagic shock and hysterectomy in 3,5,3 and 2 cases,respectively.③There were no statistical differences among gravidity,parity,and times of previous cesarean delivery between CUR group and ICUR group(P>0.05).The age of pregnant women in CUR group was significantly older than that of ICUR group(Z=14.323,P<0.001).The gestational age in CUR group was significantly smaller than that of ICUR group(Z=-32.578,P<0.001).The pregnancy interval in CUR group was significantly shorter than that of ICUR group(Z=-7.268,P<0.001).The parturient attack rate in CUR group was significantly higher than that of ICUR group(χ^2=4.720,P=0.030).④The treatment methods of 106 pregnant women included hysterectomy in 3 cases,bilateral tubal ligation and hysterorrhaphy during cesarean section in 18 cases,and just hysterorrhaphy during cesarean section in 85 cases.And 85 patients with retained fertility were followed up for 5 to 52 months,and none of them got pregnant again.Conclusions Scarred uterus in pregnant women is a primary risk factor for uterine rupture during pregnancy.The main cause of scarred uterus is cesarean section.CUR is closely related to pregnancy interval in re-pregnant women with scarred uterine after cesarean section.Uterine rupture of scarred uterus caused by non-cesarean section leads to more serious clinical complications.